Interdisciplinary Consultation Research Articles

Consequences of Virtual Visit Implementation: Considerations for Supporting Collaborative Work

Background: The use of virtual visits (i.e., phone- and video-based physician visits) has increased dramatically as a result of the COVID-19 pandemic. However, previous research indicates that implementation of this new model of care is difficult. Focusing on the work processes of patients and providers can provide important information about opportunities to optimize virtual visits so that patients and providers can experience better outcomes. Methods: We conducted a qualitative study to explore the perspectives of primary care physicians working at a large academic medical center (AMC) who used telemedicine, including virtual visits, during the COVID-19 pandemic. Semi-structured interviews with 20 physicians were conducted between July and August 2020. Interview questions asked about physicians’ challenges using telemedicine, the impacts of telemedicine on primary care work, and what helped them deliver care via telemedicine. All interviews were recorded, transcribed, coded, and rigorously analyzed using deductive thematic analysis guided by the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) framework to examine the impact of virtual visit implementation on work processes. Results: According to physicians, the use of virtual visits had positive and negative impacts on providers and patients. On one hand, virtual visits could (1) enable greater work-life balance, (2) allow for more flexibility as to when patient visits take place, (3) reduce some barriers to care and coordination of visits, (4) make patients feel comfortable interacting with their provider, (5) maintain patient-physician connections, and (6) get family members involved with the patient’s care. On the other hand, the use of virtual visits poses some challenges because they (1) necessitate coordination around “virtual rooming” and virtual visit appointments, (2) require some augmentation of virtual visits with in-person care, (3) may require a recalibration of patient expectations about virtual visits, (4) will need patients to access and use other tools to monitor their health and engage in care, (5) do not seamlessly integrate with interpreter services, and (6) infrequent interdisciplinary communication and consultations can hinder collaborative work. Conclusion: Virtual visits have been a critical element of the response to the COVID-19 pandemic, but our findings suggest the need to consider how we can retain the positive elements of this shift to virtual care while addressing issues that can reduce the negative consequences for providers and patients.

Development of a complex arts-based intervention for patients with end-stage kidney disease whilst receiving haemodialysis

BackgroundPatients with end-stage kidney disease who receive haemodialysis experience a protracted treatment regimen that can result in an increased risk of depression and anxiety. Arts-based interventions could address this unique issue; however, no arts-based interventions have been developed for delivery within a haemodialysis unit and evaluation within a randomised controlled trials (RCTs).AimTo develop a complex arts-based intervention for patients with end-stage kidney disease whilst receiving haemodialysis.MethodsThe development process utilised the Arts in Health framework (Fancourt, 2017). The framework was addressed through the establishment of an interdisciplinary advisory group, collaboration and consultation with stakeholders, a scoping and realist review, shadowing of artists-in-residence, personal arts practice and logic modelling.ResultsThe intervention involved six 1-h long, one-to-one facilitated sessions focused on creative writing and visual art. Patients could choose between art form and self-select a subject matter. The sessions had a primary focus on skill development and were delivered using principles derived from the psychological theory of flow.ConclusionThe Arts in Health framework provided an appropriate and pragmatic approach to intervention development. Complex arts-based interventions can be developed for the purpose of evaluation within a trial framework. This intervention was designed to strike a balance between standardised components, and a person-centred approach necessary to address existential boredom.

Perioperative Medicine in Visceral Surgery in the Elderly Patient from an Anaesthesiological Perspective

Demographic change is leading to an increasing number of old patients both in our society and in hospitals. With increasing age, not only the number of pre-existing conditions increases, but also the postoperative complication rate and mortality. Ultimately, however, it is not age that is decisive, but the condition of the patient and his or her capacity to face the physical and mental challenges of a surgical procedure. Frail patients are particularly at risk of complications, and an essential strategy - known as prehabilitation - is to put them in a better state pre-operatively through physical and mental training, as well as nutritional counselling. Delirium is one of the most frequent postoperative complications. Measures such as refraining from premedication with benzodiazepines, measuring the depth of anaesthesia, refraining from long-acting opioids, performing fast-track surgery, and providing glasses/hearing aids quickly postoperatively can reduce the risk of delirium. Close interdisciplinary consultation between surgeons, anaesthetists, geriatricians and physiotherapists is essential to coordinate the perioperative procedure and reduce the perioperative risk for elderly patients.

Non-invasive and invasive autonomic tests to facilitate cardioneuroablation and complex indications for transcutaneous lead extraction and discontinuation of permanent pacing

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Rare-A-Care registry Background Extracardiac vagal nerve stimulation (ECANS) and cardioneuroablation (CNA) are promising methods to cure vagally mediated bradycardia and validate indications for permanent pacing for sinus node dysfunction (SND), atrioventricular blocks (AVB), tachycardia-bradycardia syndrome (TBS) and cardio-inhibitory or mixed reflex syncope (VVS). There are limited information on clinical utility of those procedures in validation of indication for continuation of permanent pacing (PM) and transcutaneous lead extraction (TLE). Methods Data were collected from prospective multicentre registry of CNA facilitated by interdisciplinary consultations, state-of-art autonomic tests, atropine/propranolol tests, electrophysiologic study as well as ECANS. Share-decision making were used by EP-HEART-TEAM to developed patient-oriented therapy. Results Between June 2018-Jan 2021 the first 102 consecutive patients underwent interdisciplinary approach before invasive EPS and/or invasive ECANS, to consider biatrial, binodal CNA, if possible to cure functional bradycardia. Eleven (10%) patients had implanted permanent PM"s due to SND/AVB/TBS/CI-VVS and were considered for TLE. In 2 out of 11 cases CNA was not performed due to: 1) structural advanced 2nd and 3rd degree AVB with indication for TLE and permanent HBP (no.1), 2) incidental severely symptomatic persistent 3rd degree AVB more than 15 year ago without any further bradycardia episodes (only TLE, no.2). In further 9 of 11 cases with PM CNA was performed, however TLE was not attempted in 2 patients [(SND + PVC ablation + indication for beta-blocker therapy due to IHD in older male. TLE had not yet been attempted to confirm long-term success therapy by patient and/or physician (no.3); two periprocedural successful CNA resulted in disappearance of CI reflex however despite pacing syncopal events persist due to mixed etiology (no.4)]. In further 7/11 cases TLE-s were performed. Three cases had TLE prior to CNA [VVS-CI + advanced functional AVB - prior 3 pacemaker reimplantations and further "rescue" CNA, (no.5); CI-VVS + pacemaker infection (no.6); TLE of PM + TBS no.7]. Finally, in 4 cases TLE was recommended after CNA [CI-VVS (no.8, no.9 and no.10); mixed etiology: TBS + VVS-CI + intermittent, recurrent pericardial efffusion due to lead perforation, PM syndrome, (no. 11)]. Conclusions Interdisciplinary and comprehensive autonomic approach with ECANS and CNA enable EP-HEART-TEAM to offer patient-oriented therapy with a complex clinical scenarios before final decision about TLE and discontinuation of permanent pacing therapy.

Palliative Care for Patients on Extracorporeal Membrane Oxygenation for COVID-19 Infection.

Background:Critically ill patients with COVID-19 infection on extracorporeal membrane oxygenation (ECMO) face high morbidity and mortality. Palliative care consultation may benefit these patients and their families. Prior to the pandemic, our institution implemented a policy of automatic palliative care consultation for all patients on ECMO due to the high mortality, medical complexity, and psychosocial distress associated with these cases.Objectives:The main objective was to describe the role of the palliative care team for patients on ECMO for COVID-19 infection. The secondary objective was to describe the clinical outcomes for this cohort.Design:Case series.Settings/Subjects:All patients age 18 or older infected by the novel coronavirus who required cannulation on ECMO from March through July of 2020, at an urban, academic medical center in the United States. Inter-disciplinary palliative care consultation occurred for all patients.Results:Twenty-three patients (median age 43 years [range 28-64], mean body mass index 34.9 kg/m2 [SD 9.2], 65% Hispanic ethnicity) were cannulated on ECMO. Eleven patients died during the hospitalization (48%). Patients older than 50 years of age demonstrated a trend toward increased odds of death compared to those younger than 50 years of age (OR 9.1, P = 0.07). Patients received an average of 6.8 (SD 3.7) palliative clinical encounters across all disciplines. The actions provided by the palliative care team included psychosocial support and counseling, determination of surrogate decision maker (for 100% of patients), pain management (83%), and non-pain symptom management (83%).Conclusions:Here, we present one of the first studies describing the patient characteristics, outcomes, and palliative care actions for critically ill patients with COVID-19 on ECMO. Almost half of the patients in this cohort died during their hospitalization. Given the high morbidity and mortality of this condition, we recommend involvement of palliative care for patients/families with COVID-19 infection who are on ECMO. The impact of palliative care on patient and family outcomes, such as symptom control, satisfaction with communication, rates of anxiety, and grief experience merits further investigation.

Building a hospital-based addiction medicine consultation service in Vancouver, Canada: the path taken and lessons learned.

To improve evidence-based addiction care in acute care settings, many hospitals across North America are developing an inpatient addiction medicine consultation service (AMCS). St Paul's Hospital in Vancouver, Canada houses a large interdisciplinary AMCS. This study aimed to: (1) describe the current model of clinical care and its evolution over time; (2) evaluate requests for an AMCS consultation over time; (3) highlight the established clinical training opportunities and educational curriculum and (4) provide some lessons learned. A retrospective observational analysis in an urban, academic hospital in Vancouver, Canada with a large interdisciplinary AMCS, studied from 2013 to 2018, among individuals who presented to hospital and had a substance use disorder. Data were collected using the hospital's electronic medical records. The primary outcome was number of AMCS consultations over time. In 2014 the hospital's AMCS was restructured into an academic, interdisciplinary consultation service. A 228% increase in the number of consultations was observed between 2013 (1year prior to restructuring) and 2018 (1373 versus 4507, respectively; P=0.027). More than half of AMCS consultations originated from the emergency department, with this number increasing over time (55% in 2013 versus 74% in 2018). Referred patients were predominantly male (>60% in all 5years) between the ages of 45 and 65years. Reasons for consultation remained consistent and included: opioids (33%), stimulants (30%), alcohol (23%) and cannabis use (8%). After St Paul's Hospital in Vancouver, Canada was restructured in 2014 to a large, interdisciplinary addiction medicine consultation service (AMCS), the AMCS saw a 228% increase in the number of consultation requests with more than half of requests originating from the emergency department. Approximately two-thirds of consultation requests were for opioid or stimulant use.

A retrospective, 5-year, clinicoepidemiological study of severe cutaneous adverse reactions (SCARs).

A severe cutaneous adverse reaction (SCAR) is a rare, clinically heterogeneous, life-threatening phenomenon that results in serious skin damage, systemic complications, and significant morbidity or mortality comprising of Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), or SJS-TEN overlap, acute generalized exanthematous pustulosis (AGEP), exfoliative dermatitis, and drug rash with eosinophilia and systemic symptoms (DRESS). A retrospective study was conducted on all cases of SCARs admitted in a tertiary care referral hospital from January 2015 to December 2019. Clinical and epidemiological details were retrieved from the records of patients as per predesigned proforma. The data collected were analyzed and statistically evaluated. A total of 142 patients (67 males, 75 females) with SCARs, constituting 0.08% of total hospital admission and 0.027% of total dermatology outpatient department (OPD), were studied. Age group ranged from 2 to 61years, with the mean age of 33.6years (SD=17.43). Most patients belonged to SJS-TEN complex (75 cases; SJS 48, SJS-TEN 18, TEN nine) followed by exfoliative dermatitis (27 cases/19%), AGEP (26 cases/18.3%), and DRESS (14 cases/9.8%). Anticonvulsants were most commonly implicated (22%) followed by antibiotics (20%), nonsteroidal anti-inflammatory drugs (NSAIDs) (17%), and ayurvedic (7%). There was only single mortality in a DRESS patient. SCAR has considerable disease burden with marginal female preponderance in SJS/TEN and exfoliative dermatitis and can involve even the pediatric population. Anticonvulsants followed by antibiotics, NSAIDs, and ayurvedic medicines are common groups known to cause SCARs. To date, there are no definitive recommendations regarding their optimal treatment regimen, hence early diagnosis, prompt withdrawal of culprit drug, high standard of nursing care, and interdisciplinary consultations are vital steps to avoid disease progression and restore health.

Barriers and Facilitators to integrate Oral Health care for Older Adults in General (Basic) Care in East Netherlands. Part 2 Functional Integration.

Objectiveto synthesise a framework of barriers and facilitators in the functional integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels.BackgroundIdentification of these barriers and facilitators is expected to promote better and more appropriate care.MethodsFor this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home‐dwelling and nursing‐home patients) were interviewed. Transcripts of the in‐depth, topic‐guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined.ResultsTwo themes were identified: (1) compartmentalised care systems and (2) poor interprofessional and communication infrastructure. Barriers related to (1) included lack of integrative policies and compartmentalised healthcare education (macro level); poor embedding of OHC in care procedures, instruments and guidelines (meso level); and poor interprofessional skills (micro level). Barriers related to (2) included poor financial incentives for collaborative practices (macro level) and badly connected ICT systems (meso level). Identified facilitators included integration of an OHC professional into care teams, and interdisciplinary consultations (meso level); and integration of OHC in individual care plans (micro level).ConclusionIn The Netherlands, OHC for older people is at best poorly integrated into general care practices. Barriers and facilitators are interconnected across macro‐, meso‐ and micro levels and between normative and functional domains and are mainly related to compartmentalisation at all levels and to poor interprofessional and communication infrastructure.

Don’t panic: Bringing complexity thinking to UK Government evaluation guidance

Central government guidance seeks to ensure and enhance the quality of practice and decision-making across – and sometimes beyond – government. The Magenta Book, published by HM Treasury, is the key UK Government resource on policy evaluation, setting out central government guidance on how to evaluate policies, projects and programmes. The UK Centre for the Evaluation of Complexity Across the Nexus was invited to contribute its expertise to the UK Government’s 2020 update of the Magenta Book by developing an accompanying guide on policy evaluation and ‘complexity’. A small multidisciplinary team worked together to produce a set of guidance, going through multiple stages of work and drawing on a variety of sources including academic and practitioner literature and experts and stakeholders in the fields of evaluation, policy and complexity. It also drew on Centre for the Evaluation of Complexity Across the Nexus’ own work developing and testing evaluation methods for dealing with complexity in evaluation. The resulting Magenta Book 2020 Supplementary Guide: Handling Complexity in Policy Evaluation explores the implications of complexity for policy and evaluation and how evaluation can help to navigate complexity. This article, designed primarily for practitioners who might be interested in this guidance and how it was developed, describes the processes involved, particularly related to the interdisciplinary dialogue and consultation with other key stakeholders that this involved. It also briefly outlines the content and key messages in the guidance, with reflections on the experiences of the authors in developing the guide – including the challenges and insights that arose during the process, particularly around the challenges of communicating complexity to a broad audience of readers.

Barriers and facilitators to integrate oral health care for older adults in general (basic) care in East Netherlands. Part 1: Normative integration.

to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. Identification of these barriers and facilitators is expected to promote better and more appropriate care. For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).

Ascending aorta pseudoaneurysm simulating mediastinal lymphoma in computed tomography, a possible diagnostic error: a case report

BackgroundAn ascending aortic pseudoaneurysm is a severe and rare complication following cardiothoracic surgery. This case report demonstrates its possible misinterpretation and the consequent importance of multidisciplinary evaluation.Case presentationWe present a case of an 18-year-old Caucasian man with Marfan syndrome who developed an ascending aortic pseudoaneurysm about 1 year after undergoing cardiac surgery with the Bentall procedure. Computed tomographic examination of the thoracic aorta and positron emission tomography–computed tomography initially suggested a lymphomatous pathology. However, these imaging results were in contrast to the transesophageal echocardiogram and the laboratory data that showed negative results for hematological pathology. A second computed tomographic scan redirected the diagnosis toward a pseudoaneurysm.ConclusionThis case demonstrates the utility of close communication and interdisciplinary consultation between cardiovascular radiologists and the cardiac surgery team, which are mandatory in order to maximize their diagnostic skills in identifying postoperative complications.

Healing of Memories in Romania – A Bridge between Churches, Cultures and Religions – A Project of Loving one’s Neighbour

"Abstract: The Christians’ ”healing of memories” is a comprehensive project, which requires the cooperation among history, cultural studies, psychology and sociology. In Romania, the Healing of Memories project (hereinafter referred to as HoMR) has aimed at implementing the Charta Oecumenica. The project was preceded by an interconfessional and interdisciplinary study and consultation. The study compared the historic perspectives of the churches, denominations and cultures in Romania. The outstanding historical perspective of the healing of memories process aimed at gaining access to the various religious and historic perspectives, the participants learning as much as possible about each other, accept the others’ approach and share the pain caused by different historic events with each other. The project dealt with the positive relationships among the churches as well as the conflicts and the offences, judgments and misunderstandings that the different nationalities, cultures and religious denominations encountered during the centuries. Overcoming the inner, deep injuries could open new possibilities for coexistence, and Transylvania could become a role model in the future for the entire Europe. According to Johnston McMaster the concrete steps in the healing of memories are the following: ”1. a walk together in history. 2. sharing each other’s pain, 3. preparation for the future”. In the Healing of memories project, 16 theological research and educational institutions, 7 history departments and 2 sociology departments took part. Furthermore, other six institutions were contacted and over 300 colleagues participated in the workshops and conferences. What was the general objective of the HoM project? It was recollection and beyond recollection mutually getting acquainted with, understanding, accepting and sympathising with each other. The Healing of Memories project was a true success."

The Neurofibromatoses.

Neurofibromatosis of types 1 and 2 (NF1, NF2) and schwannomatosis are the diseases that make up the neurofibromatosis spectrum. With respective incidences of 1 in 3000, 1 in 33 000, and 1 in 60 000 births, they form part of the group of rare tumor-suppressor syndromes. They give rise to a greater tumor burden for the nervous system than any other type of neoplastic disease. New approaches to symptomatic treatment are emerging. This review is based on articles retrieved by a selective literature search on the pathogenesis, diagnosis, and treatment of the neurofibromatoses. NF1 and NF2 are monogenic diseases, while the genetics of schwannomatosis is complex. The three entities are clinically and pathophysiologically distinct. An important aspect of their tumor biology is the alternation of growth phases and growth pauses. Correlations between genotypes and phenotypes are variable, while new mutations and genetic mosaics are common. Ninety-nine percent of patients with NF1 have six or more café-au-lait spots by the age of 12 months; 90-95% of patients with NF2 develop bilateral vestibular schwannomas. In schwannomatosis, pain is the most prominent symptom; two-thirds of those affected develop spinal schwannomas. The severity and prognosis of these disorders are not closely correlated with the radiological findings; rather, neurologic deficits, malignant transformation, and psychosocial stress are of greater clinical importance. Advances in knowledge of pathophysiology have led to the development of targeted treatment approaches. Examples include the off-label treatment of vestibular schwannomas with bevacizumab and of plexiform neurofibromas with MEK inhibitors. Patients with neurofibromatoses need individualized care. They should be treated in centers of expertise where interdisciplinary consultation is available and new types of pharmacotherapy can be provided.

Characteristics and Impact of Post-Transplant Interdisciplinary Palliative Care Consultation in Older Allogeneic Hematopoietic Cell Transplant Recipients.

Context and Objectives: The myriad of benefits of early palliative care (PC) integration in oncology are well established, and emerging evidence suggests that PC improves symptom burden, mood, and quality of life for hematopoietic cell transplant (HCT) recipients. Specific impact of PC consultation on outcomes of older allogeneic HCT (allo-HCT) recipients, a historically high-risk population vulnerable to transplant-related complications and mortality, has not been explored. Design and Methods: In this single institution, retrospective analysis of 527 first allo-HCT recipients aged ≥60 years, we characterized 75 patients who had received post-HCT PC consultation and its association with geriatric vulnerabilities identified by pre-HCT geriatric assessment. We also examined end-of-life care outcomes among patients who died within one-year of allo-hematopoietic cell transplantation. Results: In multivariate analysis, higher disease risk, female gender, and, importantly, pre-HCT functional limitation (hazard ratio 2.35, 95% confidence interval, 1.35-4.09, p = 0.003) were associated with post-HCT PC utilization. Within one-year of hematopoietic cell transplantation, 127 patients died; among those, recipients of early PC consultation had significantly higher rates of hospice enrollment (25% vs. 9%, p = 0.019) and lower rates of hospital death (71% vs. 90%, p = 0.013), intensive care unit admission (44% vs. 75%, p = 0.001), and high-intensity medical care in last 30 days of life (46% vs. 77%, p = 0.001). Conclusions: Our results highlight important pre-HCT risk factors associated with increased PC needs posthematopoietic cell transplantation and benefits of PC involvement for older allo-HCT recipients at the end of life. Prospective studies should examine the optimal timing of PC consultation and its multidimensional benefits for older allo-HCT patients.

Liver Transplantation for Extended Criteria Hepatocellular Carcinoma Using Stable Response to Locoregional Therapy and Alpha-Fetoprotein as Selection Criteria

Introduction: Current practice to only prioritize hepatocellular carcinoma (HCC) that fulfill the Milan criteria (IN_MC) is changing, since it causes the exclusion of patients who could benefit from liver transplantation. To select patients outside MC (OUT_MC) for transplantation, we implemented extended selection criteria without up-front morphometric restrictions containing surrogate parameters of tumor biology. Methods: OUT_MC patients were considered without restrictions of morphometrics and received locoregional treatment after interdisciplinary consultation. Our dynamic selection criteria for OUT_MC patients required (IN_MUC): (1) treatment response over (2) at least 6 months and (3) alpha-fetoprotein ≤400 ng/mL over the entire evaluation period. Patients with IN_MC tumors served as control and internal validation cohort. Results: 31 of 170 liver transplant candidates were OUT_MC. Of these, 8 dropped out. The remaining 23 patients met the selection criteria and underwent transplantation. Recurrence-free survival was higher in patients transplanted IN_MC compared to those OUT_MC IN_MUC (92.2% vs. 70.8%; p = 0.026) after 5 years of follow-up. Overall survival showed no significant difference (p = 0.552). With dynamic selection of transplant candidates, recurrence could also be predicted for the IN_MC patients as internal validation cohort (c-index: 0.896; CI 0.588–0.981, p = 0.005). Conclusion: Dynamic selection criteria for the stratification of patients with OUT_MC HCCs is feasible and allows for excellent long-term results and acceptable tumor recurrence rates comparable to IN_MC patients.

Treatment algorithm for women with endometriosis in a certified Endometriosis Unit

Endometriosis is a chronic hormone-dependent disease affecting approximately 25-30% of women in the third and fourth decade. Despite its frequency, it is often detected late. The aim of this overview article was to present a standardized treatment algorithm for an interdisciplinary endometriosis consultation considering conservative and surgical approaches. Despite the frequency of endometriosis and a high number of publications dealing with the disease there is a lack of evidence in literature for standardized treatment algorithms allowing a rational diagnostic and therapeutic approach. In May 2019 we did a literature search in Medline. While finding 26702 publications under the term "endometriosis" there was only one publication for the search term "endometriosis consultation treatment algorithm." After screening the abstracts 144 publications in English, French or German language had been assessed as relevant for the diagnosis and therapy of endometriosis (143 overview articles and one guideline). Based on clinical evidence, we have developed a treatment algorithm for women with suspected endometriosis. The diagnosis includes a structured medical history with the identification of endometriosis-typical symptoms and a gynecological examination, if necessary additional examinations. The treatment algorithm is essentially divided into the phase of diagnosis and the phase of therapy as well as the prevention of recurrence or long-term treatment. A multi-professional team of visceral surgery, urology, nutritional medicine, physiotherapy and psychology can be consulted for support. The treatment of endometriosis should be multiprofessional, standardized and reproducible during specialized consultations at certified centers. So far, there are few publications on a standardized and clinically proven treatment algorithm for women with suspected endometriosis. The presented treatment algorithm could be helpful in the diagnosis and treatment of endometriosis patients, even at other centers.

Resection of recurrent glioblastoma multiforme in elderly patients: a pseudo-randomized analysis revealed clinical benefit.

Elderly patients constitute an expanding part of our society. Due to a continuously increasing life expectancy, an optimal quality of life is expected even into advanced age. Glioblastoma (GBM) is more common in older patients, but they are still often withheld from efficient treatment due to worry of worse tolerance and have a significantly worse prognosis compared to younger patients. Our retrospective observational study aimed to investigate the therapeutic benefit from a second resection in recurrent glioblastoma of elderly patients. We included a cohort of 39 elderly patients (> 65years) with a second resection as treatment option in the case of a tumor recurrence. A causal inference model was built by multiple non- and semiparametric models, which was used to identify matched patients from our elderly GBM database which comprises 538 patients. The matched cohorts were analyzed by a Cox-regression model adjusted by time-dependent covariates. The Cox-regression analysis showed a significant survival benefit (Hazard Ratio: 0.6, 95% CI 0.36-0.9, p-value = 0.0427) for the re-resected group (18.0months, 95% CI 13.97-23.2months) compared to the group without re-resection (10.1months, 95% CI 8.09-20.9months). No differences in the co-morbidities or hemato-oncological side effects during chemotherapy could be detected. Anesthetic- and surgical complications were rare and comparable to the complication rate of patients undergoing the first-line resection. Taken together, in elderly patients, re-resection is an acceptable treatment option in the recurrent state of a glioblastoma. The individual evaluation of the patients' medical status as well as the chances of withstanding general anesthesia needs to be done in close interdisciplinary consultation. If these requirements are met, elderly patients benefit from a re-resection.

Multidisciplinary approach to patients with manifestations and pulmonary complications of cystic fibrosis.

Cystic fibrosis (CF) is a genetic disease, with autosomal recessive transmission, multisystemic, characterized by a remarkable clinical polymorphism and significant lethal prospective. Respiratory manifestations dominate the clinical picture, being present in all patients. The aim of the paper was to analyze the incidence of clinical manifestations, especially respiratory ones, as well as the contribution of interdisciplinary consultations to the positive diagnosis of CF, in a group of 16 patients who were hospitalized and treated in the IInd Pediatric Clinic and IInd Medical Clinic of the Emergency County Hospital, Craiova, Romania, in a period of 20 years. The 16 patients diagnosed with and treated of CF had all shown increased values of sweat chloride concentration of over 60 mmol/L. The main symptoms and clinical signs encountered in these patients were cough (75%), sputum (62.5%), dyspnea (50%), wheezing (50%), stature hypotrophy (100%), pallor (37.5%), cyanosis (25%). All 16 patients had an acute exacerbation of chronic pulmonary disease. Of the total hospitalizations, the death was recorded only in the case of one female patient. The association of some clinical aspects specific with a positive result of the sweat test or the presence of the two pathological alleles made room for determining a positive diagnosis. The multisystemic nature of this disease requires a multidisciplinary approach to these patients. Histopathologically, there was a correspondence between lung morphological lesions and the results of imaging investigations.

A clinical study of pediatric hypomelanotic dermatoses at tertiary care center

Background: Hypopigmentary and depigmentary lesions are frequently encountered in pediatric age group which can be alarming and distressing to parents. They may be insignificant or denote an underlying multisystem disorder. Hence, a thorough medical history, clinical, Wood’s lamp examination, and an interdisciplinary consultation may aid in the correct diagnosis of these dermatoses. Objectives: The objectives of the study were to study the various hypopigmentary and depigmentary dermatoses in children attending the outpatient department of a tertiary care center in South India. Materials and Methods: A descriptive study was conducted at the outpatient department of dermatology at the tertiary care center of South India, where 121 patients aged between 0 and 18 years presenting with hypopigmentary and depigmentary skin lesions from August 2018 to August 2019 were included in the study irrespective of gender. A detailed history, clinical examination, and basic investigations were done. Results: Out of 121 children included in our study, 67 (55.37%) were girls and 54 (44.62%) were boys. The mean age of the study group was 9.8 years. The most common dermatosis observed was pityriasis alba (28.9%), followed by primary disorders of hypopigmentation (vitiligo, lichen striatus, nevus depigmentosus, nevus anemicus, halo nevus, hypomelanosis of Ito, progressive macular hypomelanosis, and blaschkoid dermatitis), post-inflammatory hypopigmentation (19.8%), pityriasis versicolor (8.2%), Hansen’s disease (3.3%), and morphea (2.4%). Conclusion: The most common hypomelanotic dermatosis noted in the present study was pityriasis alba followed by primary disorders of hypopigmentation and depigmentation. Most of the dermatoses were either self-limiting or benign in nature and required only reassurance and managed with only medical line of management. These diseases may be the reason for undue concern and anxiety in parents; hence, a thorough evaluation and management of these dermatoses are necessary.

Clinical-evolutive particularities and a multimodal therapeutic-rehabilitative approach, as well as through connected care approach, in the case of hemiplegia after ischemic cardio-embolic stroke within a polypathological context – A case report

Introduction: Cardiac embolism is one of the most common causes of embolic CVA. The recovery of patients with cardio-embolic stroke is a complex process which requires taking into account all associated pathologies (e.g. diabetes mellitus) that can play a decisive role in the evolution of the patient. A multidisciplinary team is required for such a purpose. Material and methods: The paper presents the case of a 63-year old patient with hemiplegia after an ischemic cardio-embolic stroke within a poly-pathological context. In January 2019, the patient suffered from an ischemic stroke in the carotid region with an ataxic spastic hemiparesis and left facial paresis with cerebrasthenia and bradylalia and he was admitted to “St. Ioan” Clinical Emergency Hospital in Bucharest. After the patient was stabilized and received specialized treatment, following the investigations and the interdisciplinary consultations, he received indication of neuromuscular recovery and for this reason he was admitted to our clinic. The patient was clinically and functionally evaluated, according the standardized protocols implemented in our clinic, through the assessment scales (MMSE, GOS-E and Rankin, MoCA, FIM, FAC, QoL, Asworh and Penn) and also para-clinically, in order to evaluate his biological reserve and his bearing availability of the recovery program. Results: After a complex neuro-recovery program undertaken by a multidisciplinary team formed by doctors, kinesiotherapists, medium healthcare and paramedical personnel, the patient displayed a slowly favorable evolution (hardened by his multiple associated diseases due to the above-mentioned co-morbidities) from a functional point of view with the improvement of the walking program and the increase in the muscle force and self-autonomy. Conclusion: The recovery of patients with cardio-embolic stroke is a complex process, which requires taking into account all associated pathologies that can play a decisive role in the evolution of the patient. A multidisciplinary team is required for such purposes. Key words: stroke, hemiplegia, poly-pathologic, ischemic